Background: The complex nature of the HIV /AIDS epidemic in India demands for a skilled technical and managerial human resource. India's response to the human resource capacity building initiatives for better response to HIV/AIDS seems to be impressive; however it faces some key challenges. Aim: The purpose of this paper is to identify and catalogue human resource capacity building initiatives and outline the challenges for better response to HIV/AIDS in India. Materials and Methods: We reviewed and ana­lyzed published articles and reports, grey litera­ture, including organizational websites, self-published tools and articles, non-academic reports and telephonic interview with some stakeholders. Snowballing approach was used to collect information. Results: We hope that this paper would provide an understanding of the current status of capacity building initiatives in India. We have identified certain challenges, particularly related to monitoring and evaluation that need to be addressed in capacity building programs at the planning stage. Conclusion: Moreover these challenges can be viewed as potential areas for operational research.

HIV/AIDS epidemic is in its third decade in India, significant challenges still remain. The complex nature of the HIV/AIDS epidemic, demands for a skilled technical and managerial human resource. Not only are existing human and material resources are facing constraints by the impact of the epidemic, the functions of such resources are changing, often in response to a broader and more urgent range of needs. [1],[2]

National Health Policy, 2002 and National Commission on Macroeconomics and Health clearly lay down that more than the availability of financial resources, a major barrier that limits India's ability to achieve the MDGs, is inadequate supply of the required skills and competencies. [3],[4]

India produces a large number of personnel trained in discipline of medical, social, physical and management sciences, which are critical inputs for the AIDS control programme. However, the availability of a large manpower base does not translate into capacity for HIV control efforts due to lack of core public health and HIV/AIDS related knowledge and skills. [5] HIV medicine is not a part of the curriculum for most currently practicing health care professionals at the time of their medical training. Moreover, knowledge and practices in these fields are steadily changing and therefore require constant updating.

Thus, human resource capacity building programs are most needed for sustainable response to HIV /AIDS problems in the country. As per the Comptroller and Auditor General of India (CAG) report (2004) out of 380367 health care workers in HIV/AIDS counseling only 163990 are trained amounting to 54% shortfall. [6] Whereas, out of 93882 sanctioned of doctors only 52707 (56%) are trained. Similarly out of 125303 nurses, 16323 technician and 147032 field officers only 57403 (46%) nurses, 6150 (38%) technician and 44815 (30%) field officers are trained respectively. [7],[8]

The purpose of this paper is to identify and catalogue human resource capacity building initiatives and outline the challenges for better response to HIV/AIDS in India.

Materials and Methods

This is a cross-sectional study to find out the capacity building initiatives for HIV/AIDS in India.

Data collection was done using two distinct approaches, used in parallel. Primarily data about capacity building for HIV/AIDS was abstracted through internet search, review of the published literature, desk review. Interviews and discussion were held with stakeholders to get the first hand information and their views regarding capacity building initiatives for HIV/AIDS in India.

Interview with stakeholders was held either in person or by email or telephonically, depending upon the feasibility. Snowballing approach was used to reach stakeholders like policy makers, program managers, program implementers and peers and people living with HIV/AIDS working in Public sector, universities, NGOs, CBOs development sector, international organizations etc. In all 126 persons were approached, however even after persistent follow-up, a relatively small number, that is 35 responded. The discussion was held on issues like, what current capacity building programs are being undertaken in their organizations and their views about the current capacity building programs, challenges faced by such programs and different opportunities for enhancing the capacity building initiatives for HIV/AIDS with focus on Indian context.

The internet search was conducted using the different internet search engines. Key words for HIV/AIDS capacity building initiatives in India were identified. Key words used were HIV/AIDS, capacity building, training, workshop, supportive supervision. Search was restricted to the HIV/AIDS programs offered in India. Search include all programs either short term or long term, in-service/induction training for staff working in HIV/AIDS program as well as academic programs in HIV/AIDS offered by universities or organizations. Website of National AIDS Control Organization (NACO), Ministry of Health and Family Welfare (MoHFW), Indira Gandhi National Open University (IGNOU), State AIDS Control Society (SACS), Public Health Foundation of India (PHFI), selected Medical Colleges, Public Health Institutes and Universities of India and various organizations working for HIV/AIDS in India like - Family Health International (FHI), Pathfinder International, International Labour Organization (ILO), Project Concern International (PCI), AIDS prevention and Control Programs (APAC), Karnataka Health Promotion Trust (KHPT), Avery Society, Mumbai, Swasti Health International Karnataka, Society for promoting of youth and assess, Birds Karnataka etc was searched.

We reviewed and ana­lyzed published articles and reports of the organization including the grey litera­ture like self-published tools, opinion/reviews and non academic reports.

Results

NACO's capacity building initiatives briefly presented followed by initiatives from other organizations/ institutions in India. Information related to course/program/training, organization offering program, duration, key area of capacity building, probable participants/beneficiaries was presented in matrix, wherever available. Finally key challenges and opportunities for India's HIV/AIDS capacity building initiatives in India were discussed.

Broadly two categories of capacity building initiatives, namely academic programs offered by institutions, university and some colleges and the programs that were aimed to build capacity of the staff of NGOs and implementing organizations.

NACO's response to Human resource capacity building in HIV

Emphasis on human resource capacity building in NACP I was minimal. [9] The training plan followed in NACP I was redesigned with the new standardized approach in NACP-II. An action plan was developed at the national level with clear operational guidelines and schedule of activities. The Working Groups constituted for NACP-III (2007-2012) planning have highlighted the lack of requisite capacity at all levels of the programme, in their respective focus areas. India's NACP III has recognized that the availability of the critical mass of well trained human resources is the backbone to the elaborate organizational structures, institutional arrangements and strategies proposed under NACP-III. [2],[10]

Currently NACO is involved mostly in short term programs (STP) for building capacity of organizations implementing HIV/AIDS programs supported by NACO or SACS.

Other than the government initiatives, various other agencies (National, International, and/or donor agencies) are also providing support for building India's human resource capacity for response to HIV / AIDS in close collaboration with NACO. Organizations doing human capacity building for HIV/AIDS in India are shown as a matrix [Table 1].

There was insufficient, fragmented evidence of undertaking the comprehensive needs assessment process before the launch of HIV/AIDS capacity building programs. Academic programs offer mostly certificate courses, diplomas or fellowship, and are administered as full time program, distance learning program with contact courses.

Training modules and resource material are standardized and mostly are in English language. The learning objectives mostly focused on cognitive, and in some cases, psychomotor domain.

With regards to scheduling, most of the training program were clustering in last three months of the year. [11] It was general apprehension that major time of the program implementers is spent for training.

The capacity building programs for staff working in HIV/AIDS program mostly undertake basic trainings initially, followed by onsite supportive supervision and refresher training.

Almost all the capacity building programs were doing the routine quantitative structured reporting, but detail narrative reports were infrequently documented. A very significant gap was observed with regards comprehensive evaluation of capacity building programs, for those who were undertaking it was mostly the process evaluation. Operational research and documentation of best practices and success stories for Indian context are hardly undertaken by the implementing organizations as well as by funders.

The organizations implementing capacity building programs are mostly working solitarily. It was observed that organizations which were linked with each other were implementing similar type of programs. Organizations undertaking training related to targeted interventions are poorly networked with organizations undertaking capacity building programs for care and support or counseling for ICTC counselor. Furthermore, the institutions offering academic programs have poor linkages with organizations implementing capacity building initiatives from programmatic context.

Almost all, excluding some academic program, the capacity building initiatives were program oriented and funder driven. The effort towards the sustainability seems to be completely lacking. Stakeholders interviewed were grossly unaware of the concept of sustainability of capacity building initiatives.

We undertook the opinion of the various stakeholders about the most appropriate area of capacity building for various categories of staff working for HIV/AIDS programs. The overall capacity building efforts of HIV/ AIDS programs were categorized as technical and managerial capacity building. The matrix presented in [Table 2] highlights managerial capacity building and [Table 3] highlights technical capacity building needs for various stakeholders in HIV/AIDS programs/projects, consistent with the type of work they are supposed to undertake.

Table 2: Managerial capacity building needs for various stakeholders in HIVAIDS programs / projects, consistent with the type of work they are supposed to undertake

India's response to the human resource capacity building initiatives for better response to HIV/AIDS seems to be impressive; however it faces some key challenges. Based on the information collected for the paper by various approaches, we identified some potential challenges and opportunities for the India's human resource capacity building initiatives for HIV/AIDS programs.

The key area of capacity building must go with the needs of stakeholders or implementers. Most of the stakeholders commented that capacity building programs were matched with the job that staff working in HIV/AIDS programs has to perform; however, there was not enough evidence to suggest that the comprehensive needs assessment was done before the launch of the programs.

The academic programs for capacity building in HIV/AIDS must also address the country's capacity building need for better response to HIV/AIDS, however; its implementation, assessment or evaluation may be different, so as to suit the academic requirement for award of certificate. The specific areas/thematic issues on which these academic programs are developed should address the gaps identified in needs assessment and national priority for prevention and control of HIV/AIDS.

Capacity building resource material must clearly articulate the specific learning objectives. Objective must clearly spell out cognitive domain (to achieve progressive complex learning and thinking); psychomotor domain (to demonstrate the enhanced skills in complex thinking and its application to creative problem solving); and affective domain (to achieve progressive skill building and behaviours in completing a task and develop positive attitude and feelings in addition to knowledge and skills). Currently most training programmes focus on cognitive and at the most psychomotor domain, but not necessarily the affective domain.

Currently, in many programs the resource manual used is in English and needs to be translated in the local language. Moreover, even though the curriculum and modules are standardized, there is a need to recognize the effect of socio-cultural and religious influences while developing resource material/module or tools. This issue has repeatedly come up throughout the process of evaluation of STRC of many states. [12] Stakeholders, specially the program implementers also identified the need to update the modules periodically with latest information and relevant case studies and illustration which are currently not happening.

Identification of resource person to deliver trainings is critical problem faced by many organizations implementing trainings. Even if the qualified persons are identified, the implementers are finding it difficult to avail their services as per the training calendar, as many capacity building trainings happens simultaneously, and moreover many of them are also full time employed in some other organization. The cost-opportunity paid to trainer as per the NACO guidelines is not competitive; hence resource persons prefer engaging in other work. [13]

Regular updating of trainers' skills and knowledge is important for ensuring the effectiveness of capacity building programs. However, due to busy schedule, often trainers do not attain the training of trainers for update, which may affect quality of the training conducted by them. Recently there is an effort by SACS and NACO to engage the community members as trainers, especially for training of peer educators as they can better understand the issues or ground realities while implementing programs. However, before utilizing services of community members, it must be endured that they are properly trained in content as well as in the delivery of training. The training conducted by community members must be rigorously monitored and appropriately documented to measure its impact.

While designing and implementing capacity building initiatives, planners must consider the implementing partners' and training organization /institutes time lines. Conducting majority of programs towards the end of financial year may adversely affect the quality of trainings and may hamper the performance of the implementing organizations. Such practice needs to be avoided by preparing the training calendar in advance and judiciously following it. Very often the core thematic areas also overlap in different training programs, the capacity building program planners must take these issues into consideration while planning and scheduling to avoid repetition. The follow-up training programs or refresher training should be appropriately placed and the schedule or curriculum should be need based.

With regards to documentation of capacity building process, other than routine quantitative output reporting, organizations undertaking such program should maintain process documentation of entire program. This will be useful in evaluation of the program, particularly evaluating the long term impact of the program. [13],[14],[15] At SACS level, management information system should be able to maintain and analyze data on the status of trainings provided and the training needs of all staff in state. Respective SACS as well as at NACO level there should be comprehensive database of trainers, resources, number trained, number needs to be trained. Currently this information is available in piecemeal and moreover, information of capacity building programs or trainings undertaken by organizations other than NACO, are very difficult to retrieve.

The capacity building programs must be an ongoing process to ensure the effective transfer of learning and application of the knowledge and skills acquired at their workplaces and also to explore new areas / issues at workplace that needs to be addressed in future programs. The organizers implementing the capacity building programs were trying to ensure this by following the typical process of basic training, refresher and supportive supervision. The general comment was that the capacity building initiatives actually enhance the performance of staff in HIV/AIDS program, however there no evidence to document that training were responsible for better outcome. [16],[17] Monitoring and evaluation of capacity building initiatives/training programs was a very weak link in India's HIV/AIDS capacity building initiatives. What is needed is to undertake a comprehensive assessment of impact of capacity building over the short, medium and long terms as discussed in Logic Model for M and E of Human Resource Capacity Building Initiatives in [Table 4]. Furthermore, to rigorously monitor and evaluate capacity building programs there is a need for common standardized outcome indicators. Currently most of the human resource capacity building programs for HIV/AIDS in India undertakes assessment of immediate reaction of participants about program and learning that occurred in trainings. [18] However the medium term and short term impact and its cost effectiveness of capacity building program are scarcely studied.

Efforts for operational research, dissemination and documentation of success stories are infrequently undertaken, and if done, they are not easily available in public domain. Even if they are available, they are not comprehensive, and tend to focus on the work of a single proj­ect, organization, or donor. There is a scope for developing virtual or physical libraries for this purpose. This impedes the establishment of best practices and presents a particular challenge to establishing capacity building as a proven means of improving outcome of health organizations and sys­tems. Conducting system­atic research and publishing the findings will provide evidences to donors, local implementing organiza­tions, and capacity building providers for better implementation of capacity build­ing programs. [19] Less priority on the agenda of donor / funder for monitoring and evaluation or research related to capacity building could be the reason for this.

Whatever research evidence related to capacity building is available; the implementing institutions/organizations must utilize these findings in the planning and developing new initiatives along with the findings of the needs assessment, as discussed above. Bridging this gap between research and practice requires a commitment to evidence-based decision-mak­ing and systematic incorporation of promising practices. Evidence-based decision-making is also essential in higher level decisions such as funding, strategic planning, and policy therefore; implementing organizations should facilitate the pro­cess by providing data or evidence.

A knowledge exchange network is clearly needed to maximize the impact of capacity building program at the country level. Identification, setting up and networking of training institutions and master trainers is essential at the state as well as national level for sharing best practices and learning from others experiences. To facilitate experience sharing, review meetings are successfully tried by some organizations. NACO and SACS need to develop a district or national-level database of regional resources and consultants to facilitate this process. NACO should have a comprehensive list of the resources, TOT, trainers and trained staff. SACS can also maintain the directory at their respective states.

Innovations in capacity building initiatives are rare. Traditionally the programs are offered in workshop or classroom training mode with a component of site visit or supportive supervision. NACO or academic institutes running capacity building programs should develop interactive website (web based learning or e-learning). Online courses can also be offered through such website. Material and resources (books, journal articles, case studies, success stories etc) should be periodically added to the web after validation by technical experts. Training institutions or organizations must have basic infrastructure that can help individuals to communicate and network.

Sustainability of capacity building programs is a key component of all HIV/AIDS programs. Increasing sustainability in capac­ity building can be viewed as a process for sustaining desired changes brought about even after the end of the project. This can be ensured by enhancing the implementing institute's or organizations' ability to use skills to evaluate their own performance and generate innovation and using them over time in capacity building programs. Therefore, to create the lasting impact, strategies for long term sustainability are critical aspect of any capacity building program. [19] However, the currently capacity building programs do not address this issues adequately. Capacity building program implementers and organizations must advocate and develop efforts for sustaining change after capacity building ends.

The limitation of this paper is that it only talks about human resource capacity building initiatives and do not address organizational and programmatic capacity building initiatives. The other two aspects of capacity building are equally important for sustainable response to HIV/AIDS epidemic in the country. Leadership at national, state and local level; finances; commitment and infrastructure of organizations delivering capacity building programs are critical to deliver the quality. Further studies are needed to understand these concerns in India's HIV/AIDS capacity building initiatives.

Conclusion

Human resource capacity building plays a central role in the effective implementation of HIV/AIDS programs and therefore better response to prevention and control of HIV/AIDS in India. NACP III program guidelines of India have done well by recognizing capacity building as an important objective, rather than just a process. This paper would provide an understanding of the current status of capacity building initiatives in India. We have identified certain challenges, particularly related monitoring and evaluation that need to be addressed. Moreover these challenges can be viewed as potential areas for operational research.